tbuckley/cabot-search huggingface dataset:
CD12 Citalopram-induced drug reaction with eosinophilia and systemic reaction confirmed by patch testing
Authors: Alpa Kanji, Sharan Kapadia, Sarah Wakelin
Journal: British Journal of Dermatology (2023)

Abstract A 46-year-old man was referred for investigation of an acute widespread rash and fever that started 4 weeks after commencing citalopram. Clinical and histological features were consistent with drug reaction with eosinophilia and systemic reaction (DRESS). He was not on any other medication, had no known allergies and had not previously taken a selective serotonin reuptake inhibitor (SSRI). Six months after resolution, he was patch tested to the extended British Baseline Series and citalopram (crushed tablet in 50% petrolatum). Readings on days 2 (D2) and 4 (D4) were positive for citalopram (D2 ++ and D4 +++). To investigate possible crossreactivity, he was subsequently patch tested to fluoxetine, paroxetine and sertraline (crushed tablets in 50% petrolatum), which showed a positive reaction to paroxetine [D2 (–) and D4 (+)]. Patch tests to citalopram and paroxetine were negative with no irritancy in a normal volunteer. SSRIs are extensively and increasingly used for depression and other mental health problems; 45 000 000 UK prescriptions were issued in the last financial year. Despite such widespread use, cutaneous adverse drug reactions (CADRs) appear to be rare. From 1998 to 2022, the Medicines and Healthcare products Regulatory Agency recorded 16 586 adverse reactions to citalopram, of which only 1077 (6.5%) were cutaneous. Various rashes have been reported to arise from SSRI treatment, ranging from maculopapular eruptions to toxic epidermolysis necrolysis/Stevens–Johnson syndrome. There have been isolated reports of DRESS from fluoxetine, sertraline and escitalopram (the S-enantiomer of citalopram). To our knowledge, this is the first reported case of citalopram-induced DRESS. The sensitivity and specificity of patch tests in the diagnosis of delayed CADR varies according to the drug and rash. We have found case reports of positive patch tests to sertraline and paroxetine following maculopapular exanthems. Our findings highlight a diagnostic role for patch tests with an extemporaneous preparation in SSRI-induced DRESS. SSRIs have diverse chemical structures, and we speculate that patch tests may be of benefit in identifying a safer alternative should further SSRI treatment be needed.
H18 James Clark White: a pioneer of American dermatology
Authors: Lucy Smith, Paul Devakar Yesudian
Journal: British Journal of Dermatology (2023)

Abstract James Clark White, a chemist, botanist and eminent dermatologist, was a born to a shipbuilder in Boston in 1833 and from a young age was fascinated by the natural world around him. White proceeded to study medicine at Harvard and spent a further year at the University of Vienna. He was taught by renowned dermatologists, including Ferdinand Von Hebra, whose detailed drawings and lectures in dermatology were pivotal to White’s interest in the field. White’s varied background in both chemistry and botany translated into his prolific academic work on environmental dermatoses. His famous Dermatitis Venenata: An Account of External Irritants Upon the Skin was the first to provide a collective resource of contact dermatitis, before the pathogenesis of these conditions was truly understood. Another instrumental piece, ‘A case of keratosis (ichthyosis) follicularis’ is now recognized as the first description of Darier disease, which was subsequently named Darier–White disease. White authored eight books and over 100 original articles that covered many areas of cutaneous disease. White returned to Massachusetts General Hospital where, after spending a few years in general practice, he devoted his career to skin disease. He developed the dermatology department into a centre of excellence and was ultimately appointed the first chair of dermatology. A founding member of the American Dermatology Society, and twice its chairman, he progressed to become the first full professor of dermatology in the USA. White spearheaded dermatological education at Harvard, extending the specialty training from 2 to 4 years and introduced an exit examination for residents. White is regarded as part of the vanguard that elevated American dermatology to European standards in the late nineteenth century. In his personal time, White was ardent collector of fine wines and china. He devoted much time reading and listing species of birds and plants that he encountered around his residence in Belfast, Maine. He died in September 1916. His family also had distinguished careers, including his son Charles J. White, who took over his practice to also become a professor of dermatology at Harvard Medical School; and a grandson, also named James C. White, a professor of neurosurgery at the same institution. Almost two centuries after his birth, White’s lifelong dedication to dermatology has produced many works that remain relevant and inspire the dermatologists of today.
BG10 A case of pachydermoperiostosis (primary hypertrophic osteoarthropathy)
Authors: Luke Brindley, Manrup Hunjan, Helen Lewis, Marie-Louise Lovgren, Hannah Titheradge
Journal: British Journal of Dermatology (2023)

Abstract We report a case of a 21-year-old man who was referred from the community with concern about persistent swollen and inflamed eyelids together with possible facial acne. He was known to have hypertrophic osteoarthropathy under the care of rheumatology for which he was on regular infliximab infusions. He had previously been treated with methotrexate (intolerant) azathioprine and adalimumab (lack of efficacy). He also had a long-standing history of inflammatory bowel disease and associated complications: iron-deficiency anaemia, previous choledochal cyst and biliary stricture, as well as previous deficiencies in vitamins B12, A and E. The patient was known to the genetics team, with prior genetic testing demonstrating that he is homozygous for a pathogenic SLC02A1 variant (c.1264_1265delAC). This gene encodes a prostaglandin transporter involved in mediating the uptake and clearance of prostaglandins in numerous tissues. On examination, he was found to have pronounced thickening of the facial skin, especially the forehead, alongside deep furrowing of the scalp. The eyelids were severely swollen and inflamed, with prominent straight eyelashes. There were milia present on the face predominantly on the brow and cheeks. There was clubbing of all digits on his hands and feet. The cutaneous findings were deemed all in keeping with pachydermoperiostosis. Pachydermoperiostosis, also known as primary/idiopathic hypertrophic osteoarthropathy, Touraine–Solente–Gole syndrome and Rosenfeld–Kloepfer syndrome, was first described by Friedrich in 1868. This is a rare condition, and both autosomal dominant and autosomal recessive modes of inheritance have been noted. The condition usually presents during puberty and the hallmark features are thickening and coarsening of the facial skin, periostosis and digital clubbing. Other cutaneous features can include seborrhoea with sebaceous hyperplasia, acne, hyperhidrosis and cutis verticis gyrata. Ocular manifestations include blepharoptosis, floppy eyelid syndrome, and hypertrophy of both the eyelids and palpebral conjunctiva. Crohn disease and multiple bone and joint issues are known features of the condition (Doshi D. Touraine–Solente–Gole syndrome. Orbit 2018; 37:97–101; Tabatabaei SA, Masoomi A, Soleimani M et al. Pachydermoperiostosis: a clinicopathological description. J Curr Ophthalmol 2019; 31:450–3). This reported case demonstrates both classic cutaneous and other organ system features of this rare genetic condition. It highlights the importance of being able to recognize all the associated findings when a patient presents with thickening of their facial skin and eyelids.
DS25 Postsurgical pyoderma gangrenosum successfully managed with skin grafting in a breastfeeding postpartum patient
Authors: Daniel Lyons, Siona Ni Raghallaigh
Journal: British Journal of Dermatology (2023)

Abstract A 32-year-old woman who was breastfeeding presented 7 weeks postpartum with right breast pain, swelling and erythema. A clinical diagnosis of mastitis was confirmed on ultrasound, and she was started on intravenous (IV) flucloxacillin. Initial cultures grew methicillin-sensitive Staphylococcus aureus, and clindamycin was added. She failed to improve and 6 days later an abscess was incised and drained. A vacuum-assisted closure (VAC) dressing was placed over the wound postoperatively. Over the following 3 days, she deteriorated clinically with markedly increased pain, spiking temperatures and malaise. Linezolid and metronidazole were added. On return to theatre for wound review, she had an 18 cm × 10 cm deep necrotic ulcer with purulent discharge, sparing the nipple. The breast surgeon’s concern was that of necrotizing fasciitis, and an immediate wider debridement was performed, removing all breast skin except for the nipple. Dermatology was then consulted, and a diagnosis of pyoderma gangrenosum (PG) was made. The patient was commenced on IV methylprednisolone 1 g daily for 3 days. Her temperature normalized immediately, and her C-reactive protein dropped from 141 to 27 mg L−1 in 24 h. The previously rolled, violaceous wound edges settled with no further progression. Following 3 days of steroid, ciclosporin 5 mg kg−1 daily was commenced. The right breast continued to lactate, and the very large defect now present was anticipated to pose many difficulties for the young mother. Five weeks after the initial presentation, and following multidisciplinary discussion, a biodegradable temporizing matrix (BTM; NovoSorb®) was applied, under continued dermatologist-supervised immunosuppression. The BTM took with good effect. Two weeks later, a split-thickness skin graft was applied to the BTM. The skin grafting took successfully, with no reactivation of PG postoperatively. Three months postgrafting, the patient is now being weaned off ciclosporin and remains well. Postpartum PG is rare and is predominantly reported at the site of caesarean section incision. Surgery is typically discouraged in PG owing to the risk of disease reactivation. However, surgery in this case was considered appropriate due to the rapid disease control with immunosuppression, the extent of ulceration, the expected prolonged healing period requiring exposure to the toxicity of ciclosporin and the avoidance of cribriform scarring often seen with PG. This case highlights how PG should always be considered in postpartum patients presenting with rapidly progressing, nonhealing ulcers. It also shows that, despite our usual treatment practices, in certain cases, early surgical intervention can be considered alongside ongoing immunosuppression resulting in positive patient outcomes.
CD11 Patch testing in vulval dermatoses
Authors: Christiana Stavrou, Vrinda Bajaj
Journal: British Journal of Dermatology (2023)

Abstract Patch testing is an important tool in the investigation of patients with vulval dermatoses, with a significant impact on patients with a relevant identifiable allergen. There has been little research conducted in this area, with small studies suggesting a higher rate of positivity in anogenital dermatoses (39–78%) vs. patch testing in female patients generally (35–40%) (Woodruff CM, Trivedi MK, Botto N, Kornik R. Allergic contact dermatitis of the vulva. Dermatitis 2018; 29:233–43). There is also a high rate of clinically relevant results (13–49%) (Vandeweege S, Debaene B, Lapeere H, Verstraelen H. A systematic review of allergic and irritative contact dermatitis of the vulva: the most important allergens/irritants and the role of patch testing. Contact Dermatitis 2023; 88:249–62). The aetiology of this increased rate of allergic dermatitis at this site can be attributed to a number of factors. This includes intrinsic immunological characteristics of the vulval skin, local elements including infection and urine exposure, as well as external behavioural factors. There is a lack of site-specific guidance in light of this propensity of allergic contact dermatitis in vulval dermatoses. This review examined 54 patient records retrospectively at the University Hospital North Durham from 2016 to 2021 and prospectively from July to December 2022 referred for patch testing with vulval symptoms. Forty-eight patients were included with an average age of 51 years. Itch (48%) and discomfort or soreness (28%) were the main symptoms for which patients were referred. The most frequently requested patch test batteries after the British Standard Battery were medicaments, then cortico­st­eroid. The overall positivity of this cohort was 73%, in line with the available literature. The most common allergens were nickel, followed by fragrances. Of the patients with positive patch tests, 48% were relevant. Forty per cent had a partial response on withdrawal of the allergen, and 8% had complete response. Given the psychosocial impact of vulval pruritus and discomfort and the high positivity of patch testing in these patients, further population-based research is warranted to standardize patch testing in vulval dermatoses. Additionally, a low threshold for referral for patch testing should be considered to identify any element of allergic contact dermatitis in patients with recalcitrant vulval symptoms.
PA07 (P65) Vitamin D deficiency is associated with atopic dermatitis severity in a Bangladeshi population living in the UK
Authors: Rebecca L McCarthy, Bjorn R Thomas, Soha S Tawfik, Ravinder Atkar, Bryan McDonald, Sasha Dhoat, Aaron Hughes, Edel O’Toole
Journal: British Journal of Dermatology (2023)

Abstract Atopic eczema is a common chronic inflammatory skin condition with considerable heterogeneity. South Asian people living in the UK frequently have low vitamin D levels, and those with atopic disease can present with severe eczema. The association between vitamin D insufficiency and eczema severity, and the role of vitamin D supplementation in atopic eczema is inconsistent, and it is under-researched in people with Asian ancestry living in low-ultraviolet (UV) areas. This cross-sectional study investigates the association between serum 25-hydroxy vitamin D3 [25(OH)D3] and eczema severity in a cohort of South Asian children and young adults living in the UK. Eligible participants were Bangladeshi children and young adults aged 0–30 years with eczema, participating in the THEA study. Data for the study were collected via parent/patient self-reporting, clinical history and examination, and hospital databases. Levels of 25(OH)D3 were documented retrospectively, if available, from hospital databases. Eczema severity was classified by an Eczema Area and Severity Index (EASI) score less than or greater than 10. Multivariate logistic regression was used to adjust for confounding factors. In total, 682 patients were recruited between May 2018 and December 2021. The EASI score was available for 681 participants [mean (SD) 7.9 (9.1)], and 25(OH)D3 results were available for 49.7% (n = 339). Eighty-four per cent were deficient (&amp;lt; 25 nmol L−1) or insufficient (&amp;lt; 50 nmol L−1) in 25(OH)D3. Vitamin D3 levels were inversely correlated with EASI score (Spearman’s rank R2 = –0.22; P &amp;lt; 0.001). After adjustment, there was a significant association between eczema severity (EASI &amp;gt; 10) and lowest 25(OH)D3 [odds ratio (OR) 0.973, 95% confidence interval (CI) 0.956–0.988; P &amp;lt; 0.001], working class (OR 0.542, 95% CI 0.295–0.991; P = 0.047), previous immunosuppression/biologic therapy (OR 2.432, 95% CI 1.189–5.077; P = 0.016), mild-to-moderate potency topical steroid use on the face and neck (OR 3.566, 95% CI 1.730–7.696; P &amp;lt; 0.001) and topical calcineurin inhibitor use on the face and neck (OR 3.421, 95% CI 1.140–10.288; P = 0.027). These findings demonstrate an inverse correlation between 25(OH)D3 level and eczema severity in a cohort of exclusively South Asian children and young adults living in a low-UV region. Vitamin D plays a role in the modulation of proteins required for skin barrier function and regulation of the innate immune system, suggesting that vitamin D deficiency in this population may contribute to inflammation in the skin. Further research on the role of vitamin D supplementation in atopic eczema, particularly in people with skin of colour, is required.
PS09 The raising of Lazarus: re-engagement of adults with atopic dermatitis following the advent of novel effective therapies
Authors: Cathal O’Connor, Michelle Murphy
Journal: British Journal of Dermatology (2023)

Abstract Atopic dermatitis (AD) has a devastating impact on quality of life, and persistent AD affects at least 7% of adults. Until recently, options for severe AD beyond topical therapies were limited to phototherapy and conventional immunosuppressive systemic drugs. With the advent of highly effective targeted treatments such as dupilumab and Janus kinase inhibitors (JAKi), patients with AD who had been lost to follow-up in dermatology are now returning en masse for consideration of biologic treatment or JAKi. The aim of this study was to analyse qualitatively the recapture of adults with severe AD who had previously been lost to follow-up because of disillusionment with suboptimal therapies and care. Semi-structured interviews were performed with 12 adults with severe AD to discuss their pathway to return to dermatology. Thematic analysis divided concepts into two categories: experiences of losing contact with dermatology and experiences of re-engagement with dermatology. Themes related to leaving dermatology care included the ineffectiveness of older treatments, toxicity of older treatments, attendance futility, dermatologist fatigue and ‘fizzling out’. ‘The ciclosporin would work for a few weeks but then I would have a flare, and my kidneys nearly gave out’; ‘I could tell the dermatologist was sick of looking at me. Back then I thought I was the problem, but now I think he was embarrassed because he couldn’t help me’; ‘I never decided I was going to stop going, it just ended up fizzling out and never going back.’ Themes related to re-engaging with dermatology care included social media influence, novelty, exasperation with quality of life and the life-changing improvements seen with novel treatments. ‘I saw someone on Facebook showing pictures after a few weeks on the injection and I went straight to my GP for a referral back to the dermatologist’; ‘After 60 years with eczema I just wanted to try something new, even if it killed me!’; ‘A few days after starting the tablets I left like Lazarus, it was like standing up out of a wheelchair for the first time in my life.’ This study highlights the reasons why adults with AD left dermatology services, explains why they re-engaged and deeply explores the transformative effect that novel treatments have had on the AD landscape. As adults with AD continue to return to dermatology care, the implications of increasing patient numbers needing biologic and JAKi therapy should be factored into healthcare and finance planning.
P43 Patient tolerability of adalimumab biosimilar therapy in dermatology and rheumatology: real-world experience from a large tertiary centre
Authors: Arlene McGuire, Sarah Guard, Karen Topping, Catherine Smith, Satveer Mahil, Jonathan Barker, Conn McGrath, Hannah Fox, Lucy Moorhead
Journal: British Journal of Dermatology (2023)

Abstract Adalimumab is widely used in the treatment of immune-mediated inflammatory diseases. It is the highest-spend drug in the National Health Service, costing more than £400 million annually. In 2018, adalimumab biosimilars became available, leading to substantial cost savings. However, patient tolerability of biosimilars remains underexplored. We evaluated the tolerability of adalimumab biosimilar therapy (Idacio®) in patients who were switched from Humira® in a large dermatology and rheumatology tertiary centre. We identified all patients issued with a prescription of Humira by dermatology [psoriasis and hidradenitis suppurativa (HS)] or rheumatology (rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis and Behçet disease) and analysed the number who switched to Idacio between January 2021 and March 2022. Patient electronic records were reviewed up to October 2022 to identify patients who switched back to the originator product and the documented reason for the switch. The primary outcome was the numbers of patients who were switched back from the biosimilar to the originator product. Of 769 patients issued with a prescription of Humira, 694 were switched to Idacio during the study period. Of these, 134 (19.3%) switched back to the originator product, 102 of whom (76.1%) remained on this during follow-up. The highest proportion of individuals switching back to the originator product was observed in the HS population (26.7%). The most common reasons for switching back were patient-reported loss of disease control (n = 63; 47.0%), injection pain (n = 51; 38.1%) or both (n = 10; 7.5%). The median time to switch back was 197 days (interquartile range 138–280). Of 694 patients prescribed Idacio, 32 (4.6%) were switched to an alternative biologic agent during the study period. Our experience with previous biosimilar switches within rheumatology and dermatology (etanercept, rituximab and infliximab) has resulted in few patients requiring a switch back to the originator. Our data indicate that around one in five patients in our study population switched back to the originator product. The higher proportion of patients citing injection pain may relate to the citrate excipient content or larger injection volume of the biosimilar Idacio. Loss of efficacy with time is well established with adalimumab, in part due to antidrug antibodies, and cannot be specifically attributed to the biosimilar. Switching may alter a patient’s confidence in the drug, which is particularly important when it may be a first-line therapy or the only approved biologic for a condition. Data on switch-back rates for other adalimumab biosimilars is required to understand how generalizable our findings are and the potential economic implications.